Lincoln And Hanwell Progress Of Reform In The Treatment Of The Insane From 1844 To The Present Time

Before presenting official evidence of the gradual progress in the
condition of the insane in England, we must interpose in our history a
brief reference to the development of what every one knows as the
non-restraint system of treating the insane. It is, no doubt, true that
restraint begins the moment a patient enters an asylum, under whatever
name it may be disguised, but by this term is technically meant the
non-use of mechanical restraint of the limbs by the strait waistcoat,
leg-locks, etc. If, as indeed it may be granted, it had its real origin
in the humane system of treatment introduced into England long
previously, it was in the first instance at Lincoln, and subsequently at
Hanwell, adopted as a universal method, and as a rule having almost the
sanctity of a vow.

The following table shows, in the clearest manner, by what gradual steps
the experiment was tried and carried on at the former asylum. Dr.
Charlesworth was the visiting physician and Mr. R. Gardiner Hill the
house surgeon.

Here we observe that in 1829 more than half the number of the inmates
were subjected to mechanical restraint, while in 1836, out of 115
patients, only twelve were so confined, and in 1837 there were only two
out of 130.[178] The total disuse of mechanical restraints followed.
They were, however, resorted to on one or two occasions subsequently.

In connection with the foregoing, it must be mentioned that the entries
of the visitors and the reports of the physicians alike agree in
describing the condition of the patients as much improved, the quiet of
the house increased, and the number of accidents and suicides as
materially reduced in number.

It would appear that the mitigation of restraint, as evidenced by these
minutes (which commence with 1819), "was ever the principle," to use Mr.
Hill's own words, "pressed upon the attention of the Boards of the
Lincoln Asylum by its able and humane physician, Dr. Charlesworth, at
whose suggestion many of the more cruel instruments of restraint were
long since destroyed, very many valuable improvements and facilities
gradually adopted, and machinery set in motion which has led to the
unhoped-for result of actual abolition, under a firm determination to
work out the system to its utmost applicable limits." Mr. Hill became
house surgeon in 1835; and it will be seen, by the table already given,
that the amount of restraint (which, in consequence of Dr.
Charlesworth's exertions, had already remarkably decreased) became less
and less under the united efforts of these gentlemen, until the close of
the year 1837, when restraint was entirely abolished; and while, on the
one hand, as Mr. Hill frankly acknowledges, "to his [Dr. Charlesworth's]
steady support, under many difficulties, I owe chiefly the success which
has attended my plans and labours," while Dr. Charlesworth's great
merit, both before and after Mr. Hill's appointment, must never be
overlooked, it is due to the latter gentleman to admit that he was the
first to assert the principle of the entire abolition of mechanical
restraint, as is stated in the "Fourteenth Annual Report of the Lincoln
Asylum," which report is signed by Dr. Charlesworth himself.

For a time there were, certainly, some drawbacks to the success of the
Lincoln experiment, from the serious physical effects (such as broken
ribs, etc.), which occasionally resulted from the struggles between
attendants and patients; and it is probable that, had not the experiment
been carried out on a much larger scale at Hanwell by Dr. Conolly, with
far greater success, a reaction would have ensued, of infinite injury
to the cause of the insane.

Dr. Conolly went to Hanwell in 1839; and in the first of an admirable
series of reports written by him, we read, "The article of treatment in
which the resident physician has thought it expedient to depart the most
widely from the previous practice of the asylum, has been that which
relates to the personal coercion, or forcible restraint, of the
refractory patients.... By a list of restraints appended to this report,
it will be seen that the daily number in restraint was in July so
reduced, that there were sometimes only four, and never more than
fourteen, at one time [out of eight hundred]; but, since the middle of
August, there has not been one patient in restraint on the female side
of the house; and since September 21st, not one on either side.... For
patients who take off or destroy their clothes, strong dresses are
provided, secured round the waist by a leathern belt, fastened by a
small lock.... No form of waistcoat, no hand-straps, no leg-locks, nor
any contrivance confining the trunk or limbs or any of the muscles, is
now in use. The coercion-chairs (forty in number) have been altogether
removed from the walls.... Several patients formerly consigned to them,
silent and stupid, and sinking into fatuity, may now be seen cheerfully
moving about the walls or airing-courts; and there can be no question
that they have been happily set free from a thraldom, of which one
constant and lamentable consequence was the acquisition of uncleanly
habits."

In a later report (October, 1844) Dr. Conolly observes, "After five
years' experience, I have no hesitation in recording my opinion that,
with a well-constituted governing body, animated by philanthropy,
directed by intelligence, and acting by means of proper officers
(entrusted with a due degree of authority over attendants properly
selected, and capable of exercising an efficient superintendence over
the patients), there is no asylum in the world in which all mechanical
restraints may not be abolished, not only with perfect safety, but with
incalculable advantage."

Four years ago when I visited the Lancaster Asylum, I was shown a room
containing the dire instruments of coercion formerly in use, and a most
instructive exhibition it was. At my request the superintendent, Dr.
Cassidy, has kindly provided me with the following list of these
articles: 1 cap with straps; 4 stocks to prevent biting; 2 muzzles
(leather) to cover face and fasten at the back of the head; 10 leather
gloves, of various forms, perforated with holes, and cuffs of leather or
iron; 14 double ditto, with irons for wrists; 1 kicking shoe; 11 leather
muffs with straps; 4 stout arm leathers (long sleeves with closed ends)
with cross-belt and chains; 8 heavy body straps, with shoulder-pieces,
waist-belts, cross-belts, and pairs of handcuffs attached by short
chains; 5 ditto of somewhat different make; 30 ditto, but with leather
cuffs; 2 waist straps with leather cuffs attached; 9 pairs of leather
cuffs padded; 11 pairs of leg-locks; a quantity of foot and hand cuffs
(iron), with chains and catches to fasten to a staple in the wall or
bedstead; 21-1/2 pairs of padded leather handcuffs; a larger quantity
of handcuffs, single and double, of iron; 22 sets of strong body
fastenings, very heavy chains covered with leather and iron handcuffs; a
large quantity of broad leather straps; a bag of padlocks; keys for
handcuffs, etc.

Truly the iron must have entered into the soul of many a poor lunatic in
those days. Mr. Gaskell began at once to remove handcuffs, etc., on his
appointment as superintendent, February, 1840. The disuse of restraint
is chronicled in the annual report, dated June, 1841. He resigned,
January 16, 1849, to become a Commissioner in Lunacy.

The Metropolitan Commissioners in Lunacy, as we have seen in the
previous chapter, issued a Report which forms an epoch in the history of
the care and provision for the insane in England and Wales. It should be
stated that, previous to the date of its preparation in 1844, the
following asylums had been erected under the Acts 48 Geo. III., c. 96,
and 9 Geo. IV., c. 40.

There were two asylums in operation at this date, which were declared
by local Acts county asylums, subject to the provisions of 9 Geo. IV.,
c. 40, viz. St. Peter's Hospital, Bristol, incorporated in the year
1696; and one at Haverfordwest, county of Pembroke, 1824.

Then there were the old hospitals of Bethlem and St. Luke's--the former
more specially devoted to the insane in 1547, removed from Bishopsgate
Street to Moorfields in 1676, and opened in St. George's Fields in 1815;
the latter opened July 30, 1751.

At this period there were thirty-three metropolitan licensed houses
receiving private patients only, and four which received paupers also.

The dates of opening of these thirty-three private asylums, so far as
known, were: three in the last century, to wit, in 1744, 1758, and 1759;
one in each of the following years, 1802, 1811, 1814, 1816, 1823, 1825,
1826, 1829, 1832, 1833, 1834, 1836, 1837, 1840, 1842, and 1843; and two
in 1830, 1831, 1838, and 1839.

Passing from London to the provinces, we find fifty-five provincial
licensed houses receiving private patients only, and forty-four
receiving paupers, of which one was in Wales (Briton Ferry, near
Swansea). The known dates of opening were: in 1718, Fonthill-Gifford in
Wilts; in 1744, Lea Pale House, Stoke, near Guildford; in 1766, Belle
Grove House, Newcastle-on-Tyne; in 1791, Droitwitch; and in 1792,
Ticehurst, Sussex; one in each of the following years, 1800, 1802, 1803,
1806, 1808, 1812, 1814, 1816, 1818, 1821, 1824, and 1829; two in each of
the years 1820, 1822, 1826, 1828, 1832, 1834, 1836, 1837, 1838, and
1842; three in each of the years 1825, 1831, 1839, and 1843; four in
1833; five in 1830, 1835, and 1840; and, finally, six in 1841. One of
the asylums opened in 1843 was that in Wales, containing only three
patients.

Of some asylums found by the Commissioners to be in a very disgraceful
state, one is described as "deficient in every comfort and almost every
convenience. The refractory patients were confined in strong chairs,
their arms being also fastened to the chair. One of these--a woman--was
entirely naked on both the days the Commissioners visited the asylum,
and without doubt during the night. The stench was so offensive that it
was almost impossible to remain there." In another, "in the small
cheerless day-room of the males, with only one (unglazed) window, five
men were restrained by leg-locks, called hobbles, and two were wearing,
in addition, iron handcuffs and fetters from the wrist to the ankle;
they were all tranquil. Chains were fastened to the floors in many
places, and to many of the bedsteads." The Commissioners report of
another house that "in one of the cells for the women, the dimensions of
which were eight feet by four, and in which there was no table and only
two wooden seats, we found three females confined. There was no glazing
to the window.... The two dark cells, which joined the cell used for a
day-room, are the sleeping-places for these three unfortunate beings.
Two of them sleep in two cribs in one cell.... There is no window and no
place for light or air, except a grate over the doors." The condition of
the floor and straw, on which the patients lay, it is unnecessary to
describe.

We should not be doing justice to the history of non-restraint if we did
not state in full what the Commissioners found at this period to be the
opinion of the superintendents of the asylums in England.

"During our visits," they say, "to the different asylums, we have
endeavoured to ascertain the opinions of their medical superintendents
in reference to the subject of restraint, and we will now state, in
general terms, the result of our inquiries. Of the superintendents of
asylums not employing mechanical restraint, those of the hospitals of
Lincoln, Northampton, and Haslar, and of the county asylum at Hanwell,
appear to consider that it is not necessary or advisable to resort to it
in any case whatever, except for surgical purposes. On the other hand,
the superintendent at Lancaster[182] hesitates in giving an opinion
decidedly in favour of the non-restraint system. He thinks that,
although much may be done without mechanical restraint of any kind,
there are occasionally cases in which it may not only be necessary, but
beneficial. The superintendent of the Suffolk Asylum considers that in
certain cases, and more especially in a crowded and imperfectly
constructed asylum, like the one under his charge, mechanical restraint,
judiciously applied, might be preferable to any other species of
coercion, as being both less irritating and more effectual. The
superintendent of the Gloucester Asylum states that he has adopted the
disuse of mechanical restraint, upon the conviction which his experience
has given him during a trial of nearly three years. Of the
superintendents of asylums who employ mechanical restraint, those of the
Retreat at York, of the Warneford Asylum, and of the hospitals at
Exeter, Manchester, Liverpool, and St. Luke's, consider that, although
the cases are extremely rare in which mechanical restraint should be
applied, it is, in some instances, necessary. Similar opinions are
entertained by the superintendents of the county asylums of Bedford,
Chester, Cornwall, Dorset, Kent, Norfolk, Nottingham, Leicester,
Stafford, and the West Riding of York. At the Retreat at York mechanical
or personal restraint has been always regarded as a 'necessary evil,'
but it has not been thought right to dispense with the use of a mild and
protecting personal restraint, believing that, independent of all
consideration for the safety of the attendants, and of the patients
themselves, it may in many cases be regarded as the least irritating,
and therefore the kindest, method of control. Eight of the
superintendents employing bodily restraint have stated their opinion to
be that it is in some cases beneficial as well as necessary, and
valuable as a precaution and a remedial agent; and three of them have
stated that they consider it less irritating than holding with the
hands; and one of them prefers it to seclusion.

"In all the houses receiving only private patients, restraint is
considered to be occasionally necessary, and beneficial to the
patients.... At the Cornwall Asylum, we found a man who voluntarily
wrapped his arm round with bands of cloth from the fear of striking
others. He untied the cloth himself at our request. We know the case of
one lady, who goes home when she is convalescent, but voluntarily
returns to the asylum when she perceives that her periodical attacks of
insanity are about to return, in order that she may be placed under some
restraint.

"Of the asylums entirely disusing restraint, in some of them, as we have
stated, the patients have been found tranquil and comfortable, and in
others they have been unusually excited and disturbed. Without, however,
attaching undue importance to the condition of the asylum at the time of
our visits, or to accidents that may happen under any system of managing
the insane, it is nevertheless our duty to call your Lordship's
attention to the fact that since the autumn of 1842 a patient and a
superintendent have been killed; a matron has been so seriously injured
that her life was considered to be in imminent danger (at Dr. Philp's
house at Kensington); another superintendent has been so bitten as to
cause serious apprehensions that his arm must have been amputated; and
two keepers have been injured so as to endanger their lives. These fatal
and serious injuries and accidents have been caused by dangerous
patients, and some of them in asylums where either the system of
non-coercion is voluntarily practised, or is adopted in deference to
public opinion."

The following is a brief summary of the arguments of medical officers
and superintendents advocating absolute non-restraint at that period:--

1. That their practice is the most humane, and most beneficial to the
patient; soothing instead of coercing him during irritation; and
encouraging him when tranquil to exert his faculties, in order to
acquire complete self-control.

2. That a recovery thus obtained is likely to be more permanent than if
obtained by other means; and that, in case of a tendency to relapse, the
patient will, of his own accord, be more likely to endeavour to resist
any return of his malady.

3. That mechanical restraint has a bad moral effect; that it degrades
the patient in his own opinion; that it prevents any exertion on his
part; and thus impedes his recovery.

4. That experience has demonstrated the advantage of entirely abolishing
restraint, inasmuch as the condition of some asylums, where it had been
previously practised in a moderate and very restricted degree, has been
greatly improved, with respect to the tranquillity and the appearance of
cheerfulness among the patients in general, after all mechanical
coercion has been discontinued.

5. That mechanical restraint, if used at all, is liable to great abuse
from keepers and nurses, who will often resort to it for the sake of
avoiding trouble to themselves; and who, even when well disposed towards
the patient, are not competent to judge of the extent to which it ought
to be applied.

6. The patient may be controlled as effectually without mechanical
restraint, as with it; and that the only requisites for enabling the
superintendents of asylums to dispense with the use of mechanical
restraint, are a greater number of attendants, and a better system of
classification amongst the patients; and that the additional expense
thereby incurred ought not to form a consideration where the comfort of
the patients is concerned.

On the other hand, the medical and other superintendents of lunatic
asylums who adopted a system of non-restraint as a general rule, but
made exceptions in certain extreme cases, urged the following reasons
for occasionally using some slight coercion:--

1. That it is necessary to possess, and to acquire as soon as possible,
a certain degree of authority or influence over the patient, in order to
enforce obedience to such salutary regulations as may be laid down for
his benefit.

2. That, although this authority or influence is obtained in a majority
of cases by kindness and persuasion, there are frequent instances where
these means entirely fail. That it then becomes necessary to have
recourse to other measures, and, at all events, to show the patient
that, in default of his compliance, it is in the power of the
superintendent to employ coercion.

3. That a judicious employment of authority mixed with kindness (and
sometimes with indulgence) has been found to succeed better than any
other method.

4. That the occasional use of slight mechanical restraint has, in many
instances, been found to promote tranquillity by day and rest by night.

5. That it prevents, more surely than any supervision can effect, the
patient from injuring himself or the other patients.

6. That, particularly in large establishments, the supervision must be
trusted mainly to the attendants, who are not always to be depended on,
and whose patience, in cases of protracted violence, is frequently worn
out. That in such cases mild restraint insures more completely the
safety of the attendants, and contributes much to the tranquillity and
comfort of the surrounding patients.

7. That in many cases mild mechanical restraint tends less to irritate,
and generally less to exhaust the patient, than the act of detaining him
by manual strength, or forcing him into a place of seclusion, and
leaving him at liberty to throw himself violently about for hours
together.

8. That the expense of a number of attendants--not, indeed, more than
sufficient to restrain a patient during a violent paroxysm, but
nevertheless far beyond the ordinary exigencies of the establishment--is
impracticable in asylums where only a small number of paupers are
received.

9. That the occasional use of slight coercion, particularly in
protracted cases, possesses this additional advantage: that it gives the
patient the opportunity of taking exercise in the open air at times
when, but for the use of it, he would necessarily be in a state of
seclusion.

10. The system of non-restraint cannot be safely carried into execution
without considerable additional expense; a matter which will necessarily
enter into the consideration of those who are desirous of forming a
correct opinion as to the precise benefits likely to arise from the
adoption or rejection of such a system.

11. That the benefit to the patient himself, if indeed it exist at all,
is not the only question; but that it ought to be considered, whether
the doubtful advantage to himself ought to be purchased by the danger to
which both he and his attendants and other patients are exposed, when
restraint is altogether abolished.

And 12thly. That, when a patient is forced into and secluded in a small
room or cell, it is essentially coercion in another form, and under
another name; and that it is attended with quite as bad a moral effect,
as any that can arise from mechanical restraint.[183]

Passing on to 1847, we find the Commissioners in Lunacy, having acted
under the new powers conferred upon them by the two Acts passed since
the date of the Report of 1844 (8 and 9 Vict., cc. 100 and 126), able to
give a satisfactory sketch of the progress of reform in the condition of
asylums. "In several of the county asylums and hospitals," they observe,
"the adoption of a more gentle mode of management was originally
designed in the direction of these establishments, and was the result of
public opinion and of the example set by the managers of the Retreat
near York. A strong impression was made on the feelings and opinion of
the public in reference to the treatment of lunatics by the publication
of Mr. Tuke's account of the Retreat at York. The able writings of Dr.
Conolly have of late years contributed greatly to strengthen that
impression, and to bring about a much more humane treatment of lunatics
in many provincial asylums, than that which formerly prevailed."
Referring, then, to the Report of the Metropolitan Commissioners (1844)
it is observed that "proof is afforded therein that this amendment had
not extended itself to old establishments for the insane, and that much
severe and needless restraint continued to be practised in numerous
private, and in some public asylums. In many of the private asylums, and
more especially in those which received great numbers of pauper
patients, much mechanical coercion was practised, until it came to be in
great measure laid aside in consequence of the repeated advice and
interference of the Commissioners.... In private licensed asylums it
has been thought impracticable to avoid the occasional use of
mechanical coercion without incurring the risk of serious accidents.
Under these circumstances restraint of a mild kind is still practised,
but we look forward to its abolition, except, perhaps, in some
extraordinary cases, so far as pauper patients are concerned, when the
provisions of the Act for the establishment of county asylums shall have
been carried into effect. In the best-conducted county asylums it is now
seldom (and in a few establishments never) resorted to."[184]

At this period, the actual number of lunatics returned to the
Commissioners was only 18,814, but they estimated the number under some
kind of care, in England and Wales, at 26,516. There were--

Adding the expense of maintaining many families cast upon the parish in
consequence of the patient's insanity, and the expense of supporting
many called imbecile, and the interest of large sums invested in public
establishments, the Commissioners estimated the actual amount as little
less than L1,000,000.

In the same Report the Commissioners observe "that they have found that,
with some exceptions, the patients have apparently been humanely, and
sometimes very judiciously treated. There is no reason to apprehend that
the lunatic patient is now often subjected to cruelty or
ill-treatment.... The massive bars, and rings, and chains of iron
formerly resorted to are no longer seen. Any continued coercion is not
permitted. The name of every patient under restraint and in seclusion,
and the means by which such seclusion is effected, are recorded every
week in a journal. Thus the safeguards against lunatic patients being
subjected to harsh or unnecessary restraint from the cruelty, idleness,
or caprice of their attendants, have been multiplied, and the chances of
abuse reduced to a small amount."

The number of lunatics placed under mechanical restraint in licensed
houses in this year is given in the following table, it being premised
that wherever the number is not specified, "it may be assumed either
that there was no patient then under restraint, or that the number was
so small, and the restraint so trivial, as not to be deemed worthy of
special remark."[185]

If for the purpose of comparison at different years we take one asylum,
Ringmer in Sussex, there were in November 1829, nineteen patients, of
whom five were under restraint by day, and seven by night. In 1830
(February) the number of patients was twenty, and of these eleven were
under restraint by day and six by night; while in October of the same
year, out of eighteen patients, there were nine under restraint. In
1831, there were twenty-two patients, ten of whom were under
restraint. Writing in 1848, the Commissioners enumerate the various
changes for the better which had then taken place, among which were--an
active medical superintendence; the abolition of excessive use of
mechanical restraint, there being sometimes only one or two, and
occasionally no patient whatever, under mechanical restraint; the
introduction of warm and cold baths; the cleanliness of the day-rooms

and dormitories; the addition of a good library, and various amusements
and means of occupation; and also an excellent dietary. Such is a sample
of the happy change which was, in many instances, brought about by
inspection.

The following classification of asylums in 1851 will show at a glance
the progress made in providing accommodation from time to time,
consequent upon legislation:--

1. Asylums existing prior to passing of Act 8 and 9 Vict., c. 126.

Accommodation for pauper lunatics at passing of the Act 5560
Additional accommodation provided therein since the
passing of the Act 1753
----
Total accommodation 7313

2. Asylums in progress of erection at passing of Act 8 and 9 Vict., c.
126, and since opened.

Number for which designed 997
Subsequent additions 206
----
Total present accommodation 1203

3. Asylums erected or provided under the provisions of the Act 8 and
9 Vict., c. 126, and now opened.

Accommodation for pauper lunatics 1114

4. Asylums in progress of erection under Act 8 and 9 Vict., c. 126,
and not yet opened.

For these asylums the accommodation provided in the first instance was
1114.

There were still upwards of fifty boroughs for whose pauper lunatics no
legal provision was made, and no asylum was then erected for the City of
London.

Under the head of mechanical restraint, the Commissioners now report
that it has still further diminished, and has in some houses been
absolutely abolished. However, in fifty entries made in the books of
thirty-six private asylums, abuses and defects are animadverted upon in
fifteen instances in regard to restraint, in twenty instances in regard
to bedding and clothing, nine in regard to diet, seven in regard to
cleanliness, and four in regard to management and treatment. They
observe that the number of lunatics in workhouses has diminished in a
very marked degree.

In this Report the Commissioners take the opportunity of animadverting,
also, upon the defective state of the law in regard to the property of
lunatics; the good effect of the Act 8 and 9 Vict., c. 100, being
lessened by this and other causes.

Turning to the year 1854, nearly ten years after the Act of 1845 had
been in fruitful operation, we find the Commissioners attaching
importance to the alterations recently made in the law of lunacy by the
three important statutes, 16 and 17 Vict., c. 70 (the "Lunacy Regulation
Act" of 1853) which refers to Chancery lunatics; 16 and 17 Vict., c. 90
(an amendment of the Act under which the Board was constituted); and 16
and 17 Vict., c. 97 (the "Lunatic Asylums Act," 1853).

These Acts, with 8 and 9 Vict., c. 100, and 15 and 16 Vict., c. 48, and
the Acts relative to criminal lunatics, constituted at that period the
code of law of lunacy.

New private asylums were no longer licensed for paupers, in consequence
of the accommodation provided for them in county asylums.

Complaints having been made of the treatment of patients at Hanwell, an
inquiry had been instituted, which, in the opinion of the Commissioners,
justified them. They appeared to have been due to the want of efficient
supervision of male patients.

This Report of the Commissioners gives a series of interesting replies
to a circular letter addressed to the superintendents and medical
proprietors of nearly all the asylums in England and Wales, on
non-restraint, upon which they observe, "as the general result which may
be fairly deduced from a careful examination and review of the whole
body of information thus collected, we feel ourselves fully warranted in
stating that the disuse of instrumental restraint, as unnecessary and
injurious to the patient, is practically the rule in nearly all the
public institutions in the kingdom, and generally also in the
best-conducted private asylums, even those where the restraint system,
as an abstract principle admitting of no deviation or exception, has not
in terms been adopted.

"For ourselves," they observe, "we have long been convinced, and have
steadily acted on the conviction, that the possibility of dispensing
with mechanical coercion in the management of the insane is, in a vast
majority of cases, a mere question of expense, and that its continued,
or systematic use in the asylums and licensed houses where it still
prevails must in a great measure be ascribed to their want of suitable
space and accommodations, their defective structural arrangements, or
their not possessing an adequate staff of properly qualified attendants,
and frequently to all these causes combined.

"Our matured views upon the subject will be best understood by stating
the course we have followed in the discharge of our functions as
visitors. In that capacity we have made it a principle to discourage, to
the utmost, the employment of instrumental restraint in any form.
Wherever we have found it in use, our uniform practice has been to
inquire minutely into the circumstances and reasons alleged for its
necessity, and to insist on recourse being had to those various other
means which experience has proved in other houses to be effective
substitutes for it....

"As respects the question of seclusion, its occasional use for short
periods, chiefly during paroxysms of epilepsy or violent mania, is
generally considered beneficial. At the same time, we would observe that
the facilities which seclusion holds out to harsh or indolent attendants
for getting rid of and neglecting troublesome patients under violent
attacks of mania, instead of taking pains to soothe their irritated
feelings, and work off their excitement by exercise and change of scene,
render it liable to considerable abuse; and that, as a practice, it is
open, though in a minor degree, to nearly the same objections which
apply to the more stringent forms of mechanical restraint. We are
therefore strongly of opinion that, when even seclusion is resorted to
as a means of tranquillizing the patient, it should only be employed
with the knowledge and direct sanction of the medical officer, and even
then be of very limited duration.

"Further experience, we think, has shown that, except for the reception
of epileptic patients during the continuance of their paroxysms, and in
a few cases where there is a determined propensity to suicide, the
utility of padded rooms is not so great as was at one time supposed; and
that, for cases of ordinary maniacal excitement, seclusion in a common
day-room or sleeping-room of moderate size, from which all articles that
might furnish instruments of violence or destruction have been removed,
and which is capable of being readily darkened, when required, by a
locked shutter, will, in general, be found to answer every useful
purpose."[186]

As ten years had elapsed since the first attempt of any value to present
the numbers of the insane in England (see page 211), it is of interest
to compare with the table referred to, the following statement of the
numbers on the 1st of January, 1854:--

GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE
INSANE IN ENGLAND AND WALES, JANUARY 1, 1854.[187]

In their ninth Report the Commissioners speak of continued progress,
and to show the beneficial effects of good and kind treatment, record
the case of a lady visited by them in a private asylum, where they found
her in a room by herself, in a sadly neglected condition, and very
frequently placed under mechanical restraint. Her habits were dirty, and
her opportunities of taking exercise few. In consequence of her
unsatisfactory condition the Commissioners ordered her removal to
another asylum (the York Retreat), and about twelve months afterwards
saw her there, and made an entry to the effect that since her admission
she had never been in restraint or seclusion; that her destructive and
dirty habits had been corrected by constant attention, exercise out of
doors, and association with other patients. The Commissioners found her
quiet, orderly, clean, well-dressed, and so much improved in appearance
that they had some difficulty at first in recognizing her.

It was inevitable, as a result of the attention directed to the
condition of the insane, and the greatly increased provision made for
them in consequence, that there should be an alarming apparent increase
of lunacy in the kingdom. In point of fact, the number of pauper
lunatics had increased sixty-four per cent. in the eight years ending
1855.

At this period there were 13,579 patients in county and borough asylums,
1689 in registered hospitals, 2523 in metropolitan and 2588 in
provincial licensed houses, and 114 in the Royal Naval Hospital.

The number of insane poor not in asylums was estimated at 10,500, of
whom about half were inmates of workhouses, and the remainder with
relations and strangers on an allowance from the parish.

There were various obvious explanations for the apparent increase of
lunacy, viz. the greatly enlarged accommodation; the prolongation of
life in consequence of kind care; the parochial authorities being
required to take immediate proceedings for placing violent and recent
cases under treatment; medical practitioners recognizing the nature of
cases of insanity better; facilities of post-office, railway, and press
bringing cases to light; medical officers being required to make
quarterly returns under 17 and 18 Vict., c. 97, s. 66; and the efforts
of the Commissioners to impress on guardians the importance of sending
recent cases to asylums.

The increase of private patients during eight years had been at the rate
of only fifteen per cent.; but the Commissioners point out that this
conveys an imperfect view of the relative increase of pauper and private
cases, inasmuch as a practice had sprung up by which persons who had
never been themselves in receipt of relief, and who are not infrequently
tradesmen or thriving artisans, had been permitted to place lunatic
relatives in the county asylums as pauper patients, under an arrangement
with the guardians for afterwards reimbursing to the parish the whole or
part of the charge for their maintenance.

"Indeed, it may be said with truth that, except among what are termed
the opulent classes, any protracted attack of insanity, from the heavy
expenses which its treatment entails, and the fatal interruption which
it causes to everything like active industry, seldom fails to reduce its
immediate victims, and generally also their families with them, to
poverty, and ultimately to pauperism."

The Commissioners add--and we draw special attention to the
statement--that "this is the main reason why, in our pauper lunatic
asylums, many inmates are to be met with who have formerly held a
respectable station in society, and who, in point of education and
manners, are greatly superior to the inmates of a workhouse."[188] Hence
we see how utterly fallacious is the conclusion constantly drawn from a
study of the mere figures themselves that insanity is, to the extent
indicated by them, more prevalent among the lower than the higher
classes of society.

The very great importance of obtaining good attendants for asylums
became a prominent subject now that the number of patients under
treatment had so vastly increased, and it was clearly seen that the
skill of the superintendent was of little avail unless effectually
carried out by a well-qualified staff of attendants. It was necessary
that they should be liberally remunerated, and that their position in
the house should be made comfortable. The Commissioners recommended the
appointment of head attendants of a superior class, whose duties should
not be restricted to any one ward, but who should be responsible for the
conduct of the other attendants. A well-educated lady had been found
most useful in asylums as a companion to female patients of the upper
classes. The Commissioners required notices to be transmitted to their
offices of all dismissals for misconduct of nurses or attendants, and of
the causes thereof; these notices being regularly filed for reference,
in the event of inquiries being made as to the characters of applicants
for employment.

Reviewing the condition of the insane generally at this time in
workhouses, the Commissioners were able to report that, upon the whole,
a sensible amelioration had taken place in their physical condition and
in their treatment. They abstained, however, from any official sanction
of the construction of lunatic wards in workhouses; for the patients
were not provided with any suitable occupation, the means for exercise
were generally wanting, and the attendants were too badly paid to allow
of a reliance being placed on their services.

The large number living with strangers or relatives on parish allowance
appeared to have seldom fallen within the personal observation of the
Commissioners, who had chiefly to depend upon the annual returns from
the clerks of the Board of Guardians, and on the quarterly returns from
the medical officers of the various districts,[189] whose returns were
so defective and irregular that no definite conclusion could be drawn
from their contents.

In their next Report the subject of workhouses still claimed the
attention of the Commissioners, and they complained that, in direct
contravention of the law, pauper patients were sent first to a
workhouse, instead of an asylum. The sixty-seventh section of the Act of
1853 was disregarded altogether. Hence, if the patient was found
manageable in the workhouse, he was detained there, or, if ultimately
sent to the asylum, much valuable time had been lost, and his chance of
cure greatly lessened. The Commissioners found their recommendations set
at defiance, for the most part, whenever the report of the medical
officer stated the patient to be "harmless." It was urged that the
lunatic wards in workhouses should be placed in the position of licensed
houses, and that the Commissioners and visitors should be invested with
the same power in regard to them as they possessed over these
establishments. But it became very clear that, however valuable the
recommendations of the Commissioners might, and, indeed, have ultimately
proved to be, they did not possess the authority of commands. At the
infirmary asylum at Norwich unceasing suggestions for improvement were
made for ten years, which were, "with very few exceptions,
systematically disregarded." Then, but not till then, did the
Commissioners appeal to the Secretary of State, to require the
authorities of Norwich to provide for their lunatic poor, according to
the statutes 8 and 9 Vict., c. 126, passed twelve years before. The Act
of 1853, having introduced some modification for boroughs of small
populations, left no further excuse for making proper provision. The
Commissioners from time to time issued circulars to the various asylums,
and intimated their intention to report to the Secretary of State (under
s. 29 of the Act) the cases of all boroughs wherein proper provision
had not been made for their pauper lunatics. "But even this last appeal
did not fare more successfully; and all our reiterated inquiries and
remonstrances have as yet made hardly a perceptible impression upon that
almost general neglect of the law which it was hoped they might repair."

As regards the important class of single patients, the Commissioners had
not found it practicable to visit them as they desired to do. Many,
however, had been visited. Some were found indifferently accommodated,
and otherwise in a very unsatisfactory state. The provisions of the law
were extensively evaded.[190]

As the views entertained and recommended by the Commissioners from time
to time are of importance in regard to the construction of asylums, it
may be observed that in their Report of 1857 they dwell on the evils of
very large buildings, on account of the loss of individual and
responsible supervision, the loss of the patient's individuality, and
the tendency of the rate of maintenance for patients to run higher.[191]
It was also maintained that the divided responsibility consequent on
such large institutions was injurious to management, and that the cures
of patients were actually fewer. It was considered that the limits to
the size of the Hanwell Asylum were reached, and indeed exceeded, viz.
for 1020, but room for 600 patients more was required. So at Colney
Hatch there were 1287 patients, while 713 more demanded admission. When,
in 1831, Hanwell was built for 500, it was thought sufficient to provide
for the whole of Middlesex! Two years after, however, it was full; in
another two years it was reported to contain 100 patients more than it
was built for, and after the lapse of another two years it had to be
enlarged for 300 more; Colney Hatch having been constructed for 1200
patients belonging to the same county, and opened in 1851; and yet,
within a period of less than five years, it became necessary to appeal
to the ratepayers for further accommodation, and the latest return
showed that, at the close of 1856, there were more than 1100 paupers
belonging to the county unprovided for in either of its asylums. "Hardly
had they been built, when the workhouses sent into each such a large
number of chronic cases as at once necessarily excluded the more
immediately curable, until the stage of cure was almost past; and the
doors of the establishment became virtually closed not long after they
were opened to the very inmates for whom only it was needful to have
made such costly provision." Hence the Commissioners urged separate and
cheaper asylums for old cases; but the committees of the asylums
objected. The Secretary of State induced the two parties to meet, but,
being unable to agree, the Commissioners reluctantly gave way.

In 1858 the amount of existing accommodation for pauper lunatics in the
counties and boroughs was--for males, 7516; females, 8715; total,
16,231; and the additions then being made to old asylums amounted
to--for males, 1172; females, 1309; total, 2481. The numbers for whom
additional asylums were then being made were--males, 1169; females,
1157; total, 2326. The sum of these totals being 21,048. There were, on
the 1st of January of this year, 17,572 pauper lunatics in asylums, of
whom as many as 2467 were still confined in private asylums. There were
now 33 county and 4 borough asylums, 15 registered hospitals, 37
metropolitan licensed houses, and 80 provincial licensed houses; also
the Royal Naval Hospital. The total number of inmates in these
establishments were (in the order enumerated) 15,163, 1751, 2623, 2647,
126, making a grand total of 22,310, including 295 patients found
lunatic by inquisition.

The Commissioners point out that a military asylum is a desideratum,
there being no provision for soldiers, while sailors were well cared for
at Haslar Hospital.

The following particulars will show at a glance the provision made at
this period for the insane in England and Wales:--

In 1862 the expense of pauper lunatics in asylums was thrown upon the
common fund of the union, instead of on the particular parish. The
effect was natural. Many patients were removed from workhouses to the
county asylums, some of whom might well have remained there. There could
be no objection to this, if the latter cost no more than the former; but
seeing that where the one costs L200 per bed, the other would only cost
L40, the effect is, from the point of view of the ratepayer, who usually
objects to contribute to the formation of a free library, a very serious
one.

Twenty years after the census of the insane made in 1844, and ten after
the period to which the table given at p. 230 refers, we find the
numbers as follow[192]:--

GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE
INSANE IN ENGLAND AND WALES, JANUARY 1, 1864.